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N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUE&/V <br /> Jp <br /> (Complete in Triplicate) �4�Ttip��N <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her � s application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu �e San Joaquin <br /> Local Health District: <br /> Job Address a333 wk-&c City'sl Chklftot Size PM <br /> Owner's Name Address 33.q_71 Lt 14e— —A l- Phone C1 <br /> Contractor's Name ��-1'� License No. Pho �3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LF <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE —TYPE OF WELL, PROBLEM AREA—CONSTRUCTION-SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by `f <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done i ,f <br /> Well Destruction Well Diameter Sealing Material (top 501 SQek mix V� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) Z <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms f° <br /> J <br /> Character of soil to a depth of 3 feet: Water table depth "1 <br /> SEPTIC-TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> '^LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pr perty Line E <br /> SEEPAGE PITS ❑ Depth Size - Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I "I hereby certify that I have prepared this application and that`the work willbe done in accordame with Sar Joaquin county ordinances, state laws, and4 <br /> rules and regulations of the San Joaquin Local Health District. 4-1 ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."_Contractors hiring or sub-contracting signature <br />'i certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic must call fo all requir inspections. Complete drawing on reverse side. <br /> Signed Title: /J��-!� _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ CIL Date Area�fNa,� <br /> Pit or Grout Inspection by Date err Final-Inspection by Date <br /> Additional Comments: 44 I • ��' _ } <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 []'Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rr <br /> 1 <br /> FEE1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-20{REV.10/831 I�� <br /> EH 1426 d <br />